The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

Attempt to deescalate the client.

Continue to observe the client for increased agitation.

Offer medications to help the client control behavior.

Ensure safety in the environment for the client and others.

Answer and Explanation

The Correct Answer is D

A.   Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B.   Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C.   While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D.   Ensuring the safety of the client and others is the priority in situations of escalating agitation.

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Correct Answer is C

Explanation

A. A depressant Depressants typically slow down the central nervous system, leading to
symptoms like sedation, slowed heart rate, and reduced blood pressure. The symptoms described in the question, such as tachycardia, hypertension, restlessness, and agitation, are not
characteristic of depressant use.

B. An opioid Opioids primarily lead to central nervous system depression, resulting in symptoms like respiratory depression, sedation, and decreased heart rate. The symptoms described in the question, such as tachycardia and restlessness, are not typical of opioid use.

C. A stimulant Stimulants, such as amphetamines or cocaine, lead to increased activity in the central nervous system, resulting in symptoms like tachycardia, hypertension, restlessness, and agitation. These symptoms align with the presentation described in the question.

D. An inhalant Inhalants can lead to a variety of effects, including dizziness, confusion, and sometimes increased heart rate. However, they are not typically associated with the specific symptoms of tachycardia, hypertension, restlessness, and agitation described in the question.

A. "Lab work is only needed at the start of taking the medication." B. "Once I feel better, I will not need to take this medication anymore." C. "There is a chance I may become addicted to this medication." D. "I need to be aware of situations that may cause dehydration."

Correct Answer is D

Explanation

A. "Lab work is only needed at the start of taking the medication." This statement is incorrect. Regular monitoring of lithium levels and kidney function through lab work is crucial for ensuring the medication's effectiveness and preventing potential toxicity.

B. "Once I feel better, I will not need to take this medication anymore." This statement is incorrect. Lithium is typically prescribed for long-term maintenance in bipolar disorder to prevent relapses and stabilize mood.

C. "There is a chance I may become addicted to this medication." This statement is incorrect. Lithium is not addictive. It is a mood stabilizer used to manage bipolar disorder.

D. "I need to be aware of situations that may cause dehydration." This statement demonstrates an understanding of an important consideration with lithium. Dehydration can lead to an increase in lithium levels in the body, potentially leading to toxicity. It's important for clients taking lithium to stay well hydrated and be cautious in situations that may lead to dehydration.

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The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

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Naxlex Comprehensive Predictor Exams

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